Other related deaths

Noted (AI summary) The practice will adopt a protocol to ensure GPs do not treat immediate family members, according to GMC guidelines and current Good Medical Practice guidelines. The GMC acknowledges the coroner's concerns regarding a doctor treating a close relative, referencing their guidance that this should be avoided where possible but is not explicitly forbidden. They state that they will assess if the individual poses any current and ongoing risk.

Noted (AI summary) The RYA will work with Organising Authorities to establish trends around support boats and to support Organising Authorities in managing risks associated with their events, continuing to raise awareness of responsible behavior. The Department for Transport acknowledges the concerns raised in the PFD report but states that existing legislation and guidance are sufficient, placing responsibility on local authorities and vessel operators to ensure safety. They will continue to review evidence on alcohol limits and PFD use, but do not plan to introduce national mandates.

Noted (AI summary) National Trading Standards explains their remit and states they do not have enforcement powers in this situation, recommending the Coroner contact other agencies. The HSE outlines the duties of letting agents under the Health and Safety at Work Act, but notes their undertaking is unlikely to extend to areas outside the property or managing tenant behaviour. They suggest the letting industry may wish to consider passing on information about risks beyond their direct undertaking. The agency will reinforce tenancy agreements to prohibit access to non-designated areas like roofs, issue written warnings for violations, and collaborate with Islington Council on tenant safety procedures.

Noted (AI summary) The UKHMA engaged with stakeholders and communicated findings to members, and brought the MAIB report to the PMSC steering group. They also proposed the inclusion of guidance in the GTGP, which is expected to be reviewed around Q3 2024. British Marine helped produce and publish the HSPV code in 2010, revised in 2019, and made its use a requirement of membership for operators carrying out this type of activity. The RYA has delayed review of its "Small High Speed Passenger Vessel Voluntary Code of Practice" awaiting MCA legislation, and envisages releasing a revised edition soon after the MCA Sport and Pleasure Vessel Code is finalized. The British Standards Institution acknowledges the concern regarding BS EN ISO 11591 but clarifies its role as a facilitator for expert committees to develop standards, not to interpret or regulate them; BSI will refer the concerns to the relevant technical committee. The Department for Transport states that the MCA is prioritising an updated Sport or Pleasure Vessel Code, currently under public consultation. The MCA has also been tasked to commission an anthropometric assessment of small high-speed passenger craft safety, with results expected in late spring/early summer 2026. The BPA acknowledges the concerns and has corresponded with the MAIB regarding guidance, stating the MCA should lead this. The BPA has offered to promote and amplify guidance, but is not insured to set safety-critical guidelines itself. Associated British Ports acknowledges the concerns but states that monitoring AIS tracks of vessels and intervening in their operation would be very challenging, require dedicated resources, and may not materially increase the safety of harbour users, also noting the limitations of their powers and resources for policing vessels. The MCA is working on an updated Sport or Pleasure Vessel Code, informed by the MAIB Investigation Report, which is currently undergoing public consultation. They have also begun procurement for an anthropometric assessment of small high-speed passenger craft safety, with a report expected in late spring/early summer 2026 to inform future code revisions and guidance. The UKMPG states it supports information sharing but doesn't develop guidance and believes this should be led by the MCA. They will support actions suggested but this must be led by the MCA with industry input. Red Bay Boats Limited has instructed Scot Seats to test seats to meet HSC 2000 standards; they recommend installation of Scot Seats where possible; they will not accept any commissions in the thrill-seeking market; and feel that sea safari craft should not exceed 25 knots.

Noted (AI summary) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.

Noted (AI summary) NHS England is awaiting DHSC's final ME/CFS Delivery Plan and is developing e-learning modules for healthcare professionals. They have engaged with NICE regarding guidance on ME/CFS and nutrition support, and regional colleagues are working with Royal Devon University Healthcare NHS Foundation Trust to develop formal pathways for acute admission and emergency admission for patients with ME/CFS. NICE will review evidence on dietary management for severe ME/CFS published since the 2021 guidelines and consider amendments to emphasize the need for appropriate nutritional support. It will also work with the Royal Devon University Healthcare NHS Foundation Trust to identify examples of good practice and determine if any updates to the section on fatigue are possible in NICE Clinical Knowledge Summaries. The MSC highlights that it is not a regulator but shares information about how ME/CFS is taught and assessed in medical schools, noting the GMC's new national licensing exam and examples of curriculum content. It has also shared the NHS England e-learning package on ME with medical schools. DHSC will reconvene the ME/CFS Task and Finish Group to develop a final delivery plan by the end of March 2025, focusing on research, attitudes, and education. NHS England is establishing a working group to determine additional support for commissioners, and NICE will review evidence on dietary management and strategies for severe ME/CFS and amend guidance. The MRC has invested £3.6m since 2019 in ME/CFS research in partnership with the NIHR, including co-funding the DecodeME study, and continues to engage with researchers and patient representatives to catalyse biomedical research in this area.

Noted (AI summary) Milton Keynes Council states that they adhere to a risk-based approach to highway maintenance, in line with national guidance, and that inspections did not reveal any actionable defect at the location. They will continue to fulfill their statutory obligations as the Highway Authority.